International Journal Of Occupational Health and Public Health Nursing, vol.1, no.2, 2014, 61-92
ISSN: 2053-2369 (print version), 2053-2377 (online)
Scienpress Ltd, 2014
Effects of the Mediterranean Diet on Type 2 Diabetes'
Incidence and Treatment: A Systematic Review
Panayota Kailatzi1, Margarita Matte2 and Styliani G. Tziaferi3
Abstract
The incidence of Type 2 diabetes is increasing rapidly worldwide, bringing about an
enormous economic burden for societies. Dietary habits play an important role in the
manifestation and treatment of this disease. Results from epidemiological studies and
clinical trials, suggest that adherence to the Mediterranean diet may exert beneficial
influence on glycemic control and prevention of this condition. We conducted a systematic
review aiming to determine the impact of the Mediterranean diet on glycemic control and
diabetes incidence. Electronic databases, PubMed and Google Scholar, were searched for
available publications that assessed the effect of the Mediterranean diet on type 2 diabetes.
Thirty nine studies met the inclusion criteria, sixteen explored the impact of the
Mediterranean diet on type 2 diabetes incidence, fifteen explored the impact of the
Mediterranean diet on type 2 diabetes treatment, nine explored the impact of the
Mediterranean diet on diabetes indices, as components of Metabolic syndrome and four
examined the impact of the Mediterranean diet on cardiovascular risk factors, including
type 2 diabetes. Current guidelines and recommendations from all the major scientific
associations, strongly encourage a Mediterranean-like dietary pattern for primary and
secondary prevention of major chronic diseases, including type 2 diabetes.
Keywords: Mediterranean diet, type 2 diabetes, glycemic control, HbA1c, insulin
resistance, glucose homeostasis, cardiovascular disease, metabolic syndrome
1
Introduction
Type 2 diabetes (T2D) remains the major cause of morbidity and mortality world-wide.
According to International Diabetes Federation, 382 million people suffered from diabetes
1
National and Kapodistrian University of Athens.
National and Kapodistrian University of Athens.
3
University of Peloponnese.
2
Article Info: Received : April 26, 2014. Published online : May 28, 2014
Published Online: July 31, 2014
62
Panayota Kailatzi et al.
in 2013, while this will rise to 592 million by 2035 [1] Individuals with T2D have a potent
risk for a range of complications that can lead to disability and premature death such as
renal failure, neuropathy, blindness, hypertension, peripheral vascular and cardiovascular
diseases (CVD) [2, 3]. As a result, the management of diabetes mellitus poses a huge
medical and economic burden, making it a current public health priority [4].
Although genetic predisposition and environmental influences seem to be the most
important factors responsible for the development of T2D, the increased prevalence of this
condition seems to result mainly from the lifestyle changes in modern societies. It is well
established that diabetes is a nutrient- gene- interaction disease [5-8]. The westernized
dietary patterns, physical inactivity, and the raising rates of overweight and obese people
are some of the modifiable factors that contribute to the increasing incidence of T2D.
Behavior change interventions such as dietary habits may promote healthful lifestyles,
reducing the incidence of T2D and improve glycemic control [9]. Diet quality plays an
important role to the disease manifestation. High- quality diets with low glycemic index
and glycemic load and rich in fruits and vegetables are associated with reduced risk of
chronic diseases such as MetS, CVD and T2D. This is attributed to weight balance, low
insulin response, lower blood lipids, blood pressure, blood glucose and inflammation [1014].
Foods are rarely eaten in isolation but, instead, in combination with other food groups, thus
the combined effect of food groups may create an additive effect on health [15]. Analyses
of the overall diet rather than of individual food groups takes this potential food synergy
into account. The Mediterranean diet (MeDiet) is the traditional dietary pattern of
Mediterranean region residents [16]. This diet is comprised of abundant plant
foods(vegetables, fruits, seeds, nuts and cereals), high consumption of whole grains, olive
oil, legumes, moderate to high consumption of fish, moderate to low consumption of meat,
meat products, milk and dairy products and moderate intake of alcohol (red wine) [16-19].
The MeDiet is one of the best known dietary patterns for its beneficial effects on human
health. Adherence to the MeDiet is usually measured with MeDiet scores, including a
variety of components, with higher values in these scores reflecting higher adherence to the
MeDiet. Recent studies have shown that conformity to the MeDiet protects individuals from
major chronic diseases like heart disease, cancer, Parkinson and Alzheimer. Results from
epidemiological studies and clinical trials demonstrate the beneficial role of the MeDiet
regarding the development of T2D and its treatment. High consumption of vegetables, fruits,
whole grain cereals and moderate consumption of alcohol provide antioxidants, antiinflammatory factors and dietary fiber, which have been implicated in improvements in
glucose regulation and the progression of complications associated with diabetes. Moreover,
high consumption of fish and olive oil provides a high intake of polyunsaturated and
monounsaturated fatty acids that beneficially influence insulin resistance [20-29].
Nevertheless, urbanization and globalization have altered the diet and nutrition towards the
opposite direction despite the nutritional recommendations for a healthy diet and lifestyle
[30]. Even in Mediterranean countries, dietary habits have partially changed into a more
Westernized dietary pattern. Therefore, diet evaluation for the prevention of T2D is of
significant public health importance [1, 22, 25-29, 31]. The aim of this study was to
systematically review all the available studies that have evaluated the impact of the MeDiet
in human T2D, including diabetes prevention, treatment and metabolic and cardiovascular
outcomes.
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
2
63
Methods
We searched Pubmed and Google Scholar databases for relevant articles about the effect of
the MeDiet on T2D incidence and treatment from February 2014 to May 2014. We used
the keywords Mediterranean diet, type 2 diabetes, glycemic control, HbA1c, insulin
resistance, glucose homeostasis, cardiovascular disease, metabolic syndrome, as well as
combinations of these. In addition, the reference lists of the retrieved articles helped us to
find relevant articles that did not allocate through database searching procedure. We
narrowed the search to studies published in English between 2003 and 2014, and limited to
those conducted in humans. We excluded studies that analyzed adherence to a non-specific
dietary pattern. We also excluded studies with less than 3 months follow- up and those with
gestational or type 1 diabetes population. We focused the search on articles referring to the
MeDiet as a whole dietary pattern and excluded studies that only investigated one aspect of
the MeDiet. Moreover, reports with restricted calorie intake or those that aimed to reduce
body weight, were discarded.
3
Results
A total of 129 articles were identified in the initial search, of which we excluded 41 on the
basis of the title or abstract due to the deliberation of only one of the two aspects (T2D or
MeDiet). Of the remaining 88 articles were discarded 49 for the following reasons: a non
specific dietary pattern instead of a MeDiet was evaluated (n=8), the study population had
gestational or type 1 diabetes (n=3), the follow-up was less than 3 months (n=3), including
2 studies that were published before 2003, studies with restricted calories or those aimed to
reduce body weight (n=8), studies regarding specific foods of MeDiet (n=25) and those that
were not written in English (n=1). Thirty nine studies met the inclusion criteria (Figure
1). Of these, we identified 18 observational studies (7 prospective cohort studies, 8 crosssectional studies, 1 retrospective study, 1 case- cohort prospective study and 2 both crosssectional and prospective studies), 12 intervention studies (2 of them were cross- over and
10 randomized trials), and 8 reviews.
From the total of 39 studies (Table 1), 31 took place in European countries, of them, 26
conducted in the Mediterranean region, four in north Europe and one was multicenter. Five
studies conducted in USA, two in Australia and one in Asia. The number of subjects ranged
from 12 to 41.614 participants. Greater adherence to the MeDiet was associated with older
age [32, 46, 57, 58], being female [34, 35, 46, 57, 58], better education [33,35], higher
incomes [36], smaller waist circumference [36], non- smoking [36, 46, 57, 58], more
physically active individuals [57], multivitamin users [46], ERT users [46], slightly
greater BMI [58], hypertension [58] and previous acute myocardial infarction [58]. In
contrast, the study of Panagiotakos et al [55], found no difference between the two sexes,
while in another study [34], age, physical activity, education and consumption of
antiplatelet β- blocker agents had no difference between conformity groups.
3.1 Diabetes Incidence
Given the dramatic increase of T2D prevalence nowadays, strategies aiming to prevent the
disease manifestation are of major public health priority. The association between MeDiet
adherence and the incidence of T2D was assessed in 7 prospective studies [32, 33, 35, 37,
64
Panayota Kailatzi et al.
49, 50, 58], three cross- sectional studies [25, 55, 62], one case- cohort prospective study
[39], three reviews [44, 28, 64] and two randomized controlled trials [65,42].
The most available prospective studies support the protective role of the MeDiet against
T2D development. The protecting reduction risk ranges from 9% to 83% for patients closely
adhered to the MeDiet, compared to those with the lowest adherence, after adjustment for
several confounding factors such as smoking, BMI, age, sex, family history of T2D,
physical activity, etc. [33, 34, 37, 39, 50, 58] Moreover a high MeDiet score together with
a low GL, offer protection of about 20% against diabetes. Interestingly, the MeDiet not
only has a beneficial effect on healthy adults, but also on individuals with recent myocardial
infarction. Specifically, Mozzaffarian et al [58], found that prevention of weight gain,
smoking cessation and consumption of the MeDiet, offer a protective effect on T2D
incidence on this patient group. It should be noted that dietary pattern scores such as the
alternative HEI (Healthy Eating Index), the DASH (Dietary Approaches to Stop
Hypertenson) [37] and the Healthy eating pattern [49] scores were associated with a lower
risk on T2D incidence, emerging that a common dietary pattern characterized by plant
based foods, fruits, whole- meal bread, low- fat dairy, moderate alcohol and low intake of
red meat may beneficially influence the T2D odds.
Cross- sectional evidence regarding the association between adherence to MeDiet and the
likelihood of T2D, demonstrate the beneficial role of MeDiet to T2D incidence. It is
noteworthy that both Panagiotakos et al [55] and Sanchez- Tainta et al [25] discovered
that following the MeDiet is inversely associated not only with the clustering of diabetes,
but also with hypertension, obesity, and hypercholesterolemia among high cardiovascular
risk and elderly individuals. In another cross-sectional study of Panagiotakos et al [62],
3042 participants took part in order to evaluate the incidence of T2D in relation to both
physical activity and dietary patterns. The study revealed that a 10- point increase in the
MeDiet score was associated with 21% lower odds of acquiring diabetes. The study adds
that commitment to the MeDiet together with light physical activity can reduce diabetes
risk by 35%, compared to sedentary individuals.
One large case cohort, multicenter prospective study showed that individuals with a high
MeDiet score were 12% less likely to develop diabetes than those with low MeDiet scores.
Additionally, a two- point increase in the MeDiet score was associated with a 4% reduction
in the risk of T2D. It should be noted that the association between the two variables was
attenuated in obese participants, compared to the youngest ones.
Finally, two randomized controlled trials searched the relation between MeDiet and the
incidence of T2D. Salas Salvado et al, [42] compared the effects of two MeDiets
supplemented with olive oil or nuts, versus a low- fat diet on the incidence of T2D in 418
non diabetic participants at high cardiovascular risk. The study found that MeDiet with
either olive oil or nuts reduces diabetes incidence by 52%, compared with the low-fat
dietary pattern. Similarly, later in 2014 Salas Salvado et al, [65] found that a MeDiet
supplemented with extra olive oil and without energy restriction, succeeded in limiting the
incidence of T2D among high cardiovascular risk patients
3.2 Diabetes Treatment
Fifteen studies explored the relationship between MeDiet and glycaemic control. Of them,
five were cross- sectional studies [41, 35, 45, 51, 54], two were randomized cross- over
intervention studies [36, 41], three were reviews [44] and five were randomized trials [66,
65, 43, 56, 59]. Most of these studies demonstrate the beneficial effect of the MeDiet in
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
65
T2D patient’s glycemic control and insulin sensitivity.
Cross- sectional research results show the salutary effect of the MeDiet to both diabetic and
non- diabetic participants. Evidence reveals that non- diabetic participants, consisted with
the MeDiet, had lower insulin levels, blood glucose (4), and better fasting indices of glucose
homoeostasis [54]. Additionally, in diabetic patients with greater attach to the MeDiet, was
observed reduced HbA1c and post- meal glucose concentrations [45].
Cross- over intervention studies of Ryan et al [36] and Itsiopoulos et al (9), included of
non- diabetic and diabetic participants respectively. Both studies found that insulin
sensitivity improved with the MeDiet. Furthermore, Itsiopoulos observed that consumption
of the MeDiet fell HbA1c from 7.1% to 6.8%, compared to the usual diet. Liver steatosis
reduced with MeDiet, compared with low fat/high carbohydrate diet in participants with
NAFLD [36].
Two randomized intervention trials carried out in non- Mediterranean countries, in order to
evaluate the effect of the MeDiet on diabetes markers at diabetic population. The study of
Lindeberg et al [56] failed to prove any significant correlation between these variables.
Particularly, Lindeberg et al estimated the effect of the Paleolithic diet, based on fish, fruits,
eggs, nuts, root vegetables and lean meat, compared to the MeDiet on glucose tolerance
and postchallenge insulin response in glucose intolerant IHD patients. The study
recommends that healthy diets, such as the MeDiet constitute the second best choice for the
prevention and control of diabetes condition. On the other hand, Elhayany et al [43],
compared two MeDiets, a low carbohydrate MeDiet (LCM) and the traditional MeDiet, to
the 2003 American Diabetic Association diet (ADA) between overweight diabetic patients,
and found that only the LCM had a significant impact on improving glycaemic control in
this population group. Additionally, the recent report of Esposito et al [64] supports that a
LCM can improve not only diabetes indices, but also can delay the need for medication use
between overweight, diabetic individuals.
3.3 MeDiet and MetS
We identified five primary studies that assessed the association between the MeDiet and
diabetes indices, as components of MetS [34, 38, 46, 57, 59] and four reviews [12, 47, 48,
52].
The sum of the reviews ended up that the MeDiet has an anti-inflammatory impact against
diseases related to chronic inflammation, including abdominal obesity, MetS and T2D.
Traits of MetS such as insulin resistance, hypertension and dyslipidemia are attenuated with
the consumption of the MeDiet.
Regarding the impact of the MeDiet on the incidence of MetS, Tortosa et al prospectively
found that the MeDiet reduces the odds of acquiring MetS together with all risk factors that
are responsible for its development, except plasma glucose. Additionally, the prospective
study of Rumawas et al [46] found that MetS prevalence was significantly reduced with
MeDiet. Moreover, MetS traits were attenuated (less abdominal obesity, less insulin
resistance, and less atherogenic dyslipidemia).
Moreover, the cross- sectional study of Viscogliosi et al [34] searched the incidence of
MetS and the insulin resistance and fasting glucose levels among non diabetics. They
observed that MeDiet protects against MetS and prediabetes, and improves glucose
metabolism. Similarly, Gouveri et al [38] observed a reduced incidence of MetS and a
subsequent benefit on T2D and CVD development with the commitment to the MeDiet. In
contrary, Michalsen et al [59] examined the impact of MeDiet on patients with treated CAD
66
Panayota Kailatzi et al.
with regard to inflammation and metabolic risk factors. Commitment to the MeDiet had no
effect on indices of inflammation and metabolic risk factors, including fasting insulin.
3.4 MeDiet and Cardiovascular Disease
Three randomized controlled trials [60, 61, 63] and one review [47], were identified in order
to test the effectiveness of the MeDiet on cardiovascular risk factors. Champagne et al [47]
carried out a review in 2009 ending up that individuals consuming the MeDiet pattern
derive advantage against the development of MetS and CVD. Vincent- Baudry et al [31]
conducted an intervention study of 212 overweight and obese participants with moderate
CVD risk factors who classified into a MeDiet or a low- fat diet group. The study showed
that both diets had a beneficial effect on CVD risk factors, including insulinemia, glycemia,
and HOMA score. Particularly, a 9% reduction was observed in CVD risk with the low- fat
diet and a 15% reduction with the MeDiet. Furthermore, in another randomized trial, 772
participants at high cardiovascular risk were classified into a MeDiet group with olive oil,
a MeDiet group with nuts, or a low- fat group. Both MeDiets improved blood pressure,
lipid profiles, reduced insulin resistance and decreased concentrations of inflammatory
molecules, compared with the low- fat group. As a result, both MeDiets exert a beneficial
effect on CVD risk factors [60]. Finally, Toobet et al [63], investigated the impact of the
Mediterranean Lifestyle Program on CVD. He found that stress management, exercise,
smoking cessation and the Mediterranean low- saturated fat diet, improved glycemic
control, some coronary heart disease risk factors and the overall quality of life.
4
Labels of Figures and Tables
Total studies (n=129)
Studies excluded on the basis of the title or abstract
due to the deliberation of only one of the two aspects
(T2D and MeDiet) (n=41)
88 studies
Studies excluded due to the non specific dietary
pattern(n=8), type 1 diabetes population (n=3),
follow-up less than 3 months (n=3), restricted
calorie/weight loss (n=8), components of MeDiet only
(n=25), in different than English language (n=1)
39 assessed for eligibility
Figure 1: Diagram flow of literature review
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
67
Table 1: Studies exploring the effect of the Mediterranean diet on type 2 diabetes mellitus incidence and treatment
Author/Year
Publication
Salas- Salvado
et al., 2014
Lasa et al., 2014
Countr
y
Spain
Spain
Type of study
Population
Randomized trial
3541
patients,
aged 55 to 80
years
Randomized
controlled trial
191 participants
(77 men and 114
women)
Criteria for
inclusion/excursion
Patients without T2D
but
at
high
cardiovascular
risk
were eligible for the
study
Participants with T2D
were included
Objective
Methodology
To assess the efficacy of
MeDiets for the primary
prevention of diabetes
Participants
were
randomly assigned to 1
of
3
nutrition
interventions: MeDiet
with extra- virgin olive
oil (EVOO),MeDiet
supplemented
with
mixed nuts, or a
control diet (advice on
a low fat diet)
The aim of this work was to
compare the effect of two
Mediterranean diets versus a
low-fat diet on several
parameters
and
indices
related to glycaemic control
in type 2 diabetic subjects
Participants
were
assigned to 1 of 3
nutrition interventions:
two
Mediterranean
diets
supplemented
with virgin olive oil
(n=67) or mixed nuts
(n=74) and a low-fat
diet (n=50). Insulin
resistance
was
measured by HOMAIR
index,
adiponectin/leptin and
adiponectin/HOMA-R
ratios
Follo
w up
Median of
4.1 years
-
-
1 year
-
-
-
Esposito et al.,
2014
Italy
Randomized trial
215 overweight,
middle-aged
men and women
with
newly
diagnosed T2D
Participants with T2D
were included
To assess the long-term
effects
of
dietary
interventions on glycemic
control, need for diabetes
medications, and remission
Participants
were
randomized to a lowcarbohydrate MeDiet
diet (n = 108) or a lowfat diet (n = 107). After
6.1 years
-
Results
Conclusion
80, 92, and 101 newonset cases of T2D
occurred in the
MeDiet with EVOO,
MeDiet with mixed
nuts, and control diet
groups, respectively
Multivariateadjusted hazard ratios
were 0.6 for the
MeDiet with EVOO,
and 0.82 for the
MeDiet with nuts
compared with the
control diet
Increased values of
adiponectin/leptin
ratio (P=0.043,
P=0.001 and P<0.001
for low-fat, olive oil
and nut diets,
respectively) and
adiponectin/HOMAIR ratio (P=0.061,
P=0.027 and P=0.069
for low-fat, olive oil
and nut diets,
respectively)
Decreased values of
waist circumference
(P=0.003, P=0.001
and P=0.001 for lowfat, olive oil and nut
diets, respectively)
were observed in the
three groups
In both
Mediterranean diet
groups, but not in the
low-fat diet group,
the variation above
was associated with a
significant reduction
in body weight
(P=0.347, P=0.003
and P=0.021 for lowfat, olive oil and nut
diets, respectively)
The primary end
point was reached in
all participants after a
total follow-up of 6.1
years in the low-fat
A MeDiet enriched
with EVOO but
without
energy
restrictions reduced
diabetes risk among
persons with high
cardiovascular risk
Mediterranean diets
supplemented with
virgin olive oil or
nuts reduced total
body weight and
improved
glucose
metabolism to the
same extent as the
usually
recommended lowfat diet
In patients with
newly
diagnosed
type 2 diabetes, an
LCMD resulted in a
greater reduction of
68
Panayota Kailatzi et al.
of type 2 diabetes
Georgoulis
al., 2014
et
Greece
Review
-
-
To examine current scientific
knowledge on the association
between the MeDiet and
diabetes mellitus
4 years, participants
who were still free of
diabetes medications
were further followed
up until the need of a
diabetic
drug.
Remission of diabetes
(partial or complete)
and changes in weight,
glycemic control, and
cardiovascular
risk
factors were also
evaluated
-
-
-
-
-
-
-
group and 8.1 years
in the low
carbohydrate MeDiet
group
Median survival time
was 2.8 years and 4.8
years, respectively
Low carbohydrate
MeDiet participants
were more likely to
experience any
remission (partial or
complete), with a
prevalence of 14.7%
during the first year
and 5.0% during year
6 compared with
4.1% at year 1 and
0% at year 6 in the
low-fat diet group
HbA1c levels, higher
rate of diabetes
remission,
and
delayed need for
diabetes medication
compared with a
low-fat diet
According to
epidemiological data,
a greater adherence
to the MeDiet, is
inversely associated
with T2D risk in the
general population,
in individuals at high
cardiovascular risk
and in patients with
established CVD
International studies
also demonstrate the
beneficial role of the
MeDiet in T2D
management, with
patients allocated to a
MeDiet exhibited
greater
improvements in
glycemic control and
CVD risk factors,
compared with those
following a control
diet
There is evidence
that MeDiet may also
have a beneficial role
in the primary and
secondary prevention
of CVD and a
favorable effect on
liver and sexual
function in diabetic
patients
Mounting evidence
suggests
the
beneficial effect of
the MeDiet on T2D
prevention
and
treatment
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
Esposito et al.,
2014
Italy
Review
-
-
To review the impact of
MeDiet on T2D
69
-
-
-
-
-
Dominguez
al.,2013
et
Spain
Cross
sectional/prospectiv
e cohort study
20.155
individuals for
cross- sectional
analyses,
&
9.109 individuals
for longitudinal
analysis,
university
graduatesformer students,
non- obese with
mean age 38.4
years
Excluded participants:
- with energy intake out
of
<800
or
>8000kcal/day for men
and
<500
or
>6000kcal/day
for
women
- with cancer, CVD,
and
diabetes
at
baseline,
with
missing
information
- without at least a 2year follow up
To
evaluate
the
macronutrient distribution,
assessed with MDS or
MEDAS scoring systems. To
evaluate disease incidence or
mortality, associated with
adherence to MeDiet
Individuals completed
a
validated
FFQ,
together with other
questionnaires
that
collected
sociodemographic,
lifestyle and clinical
characteristics.
Participants returned
completed
questionnaires every 2
years
Mean time:
6.2 years
-
-
-
-
Rossi
2013
et
al.,
Italy
Prospective cohort
study
22.295
participants
Excluded participants
who:
- did not respond or
could not be traced
during follow up
- had diabetes, cancer
and/ or stroke and/or
CVD
- had missing values of
the
covariates
of
interest
To investigate the association
between MeDiet and GL with
diabetes incidence
Participants completed
a validated FFQ at
enrolment. Adherence
to MeDiet and dietary
GL were calculated
from MDS score
Mean time:
11.34 years
-
-
-
-
Prospective studies
report a lower risk of
T2D in healthy
people or at risk
patients with the
highest adherence to
a MeDiet
MeDiet improved
HbA1c levels from
0.1% to 0.6%
No trial reported
worsening of
glycaemic control
with a MeDiet
The macronutrient
distribution, disease
incidence and
mortality had
similar prediction for
both scoring systems
Adherence to MeDiet
was associated with
reduced occurrence
of diabetes, CVD or
death
Most participants had
intermediate values
of adherence to
MeDiet (3-5points on
a 0- 9 point scale:
62.9%)
Compliance with
MeDiet increased
with age
Participants in the
highest quartile of
adherence to the MD
(MDS > 5)
exhibited a 12%
(95% CI 0.78–0.99)
reduced
risk
of
T2DM,
compared
with
those in the lowest
quartile (MDS < 4)
Adherence with
MeDiet increased
with better educated
participants
Older participants
reported a diet with a
lower GL, compared
with younger ones
MeDiet reduced
diabetes risk
independently of GL
levels
Adopting a MeDiet
may help prevent
T2D. Moreover ,
lower carbohydrate
MeDiet seems good
for HbA1c reduction
in persons with
established diabetes
Adherence
to
MeDiet
was
associated with a
decreased incidence
of T2D, CVD, and
all- cause mortality
A low GL diet that
also
adequately
adheres
to
the
principles of the
traditional MedDiet
may reduce the
incidence of T2D
70
Panayota Kailatzi et al.
-
-
Viscogliosi
al., 2013
et
Italy
Cross sectional
120 individuals
with mean age
59.8± 10.2 years
Excluded participants:
-who changed their
dietary habits within
the last year
- with diabetes
- with history of CHD,
stroke, ischemic attack
- with cardiovascular
events and chronic
diseases except blood
hypertension, obesity,
dyslipidemia, IFG
taking
antiinflammatory agents,
statins or other lipidlowering agents
- current or former
smokers
with
daily
consumption of more
than 2 glasses of
alcohol for women and
more than 3 for men for
a
period
of
6
consecutive months
To investigate whether the
commitment with MeDiet
affects the prevalence of
MetS,
impaires
fasting
glucose, insulin resistance
and microinflamation
- Commitment with
MeDiet was calculated
with a validated 14item questionnaire
- venous blood sample
for FBG, triglycerides,
HDL-C,
fasting
insulin, CRP
- face to face interview
for
medical
patient/family history,
lifestyle habits and
home therapy
-
-
-
-
-
-
-
-
Abiemo et al.,
2013
USA
Cross
sectional/prospectiv
e cohort study
5390
multiethnic men and
women aged 4584 years, free of
diabetes
and
CVD
Subjects with CVD or
T2D excluded from the
study
To investigate if conformity
to the MeDiet is related
cross- sectional ly with lower
insulin
resistance
and
prospectively with reduced
risk of T2D incidence
Five
examinations
during
follow up
which
included
questionnaire
information
from
participants, physical
measurements
and
tests, blood sample,
CT,
MRI,
and
6 years
-
-
Both MeDiet and
GL/GI associated
with a lower diabetes
risk
A high MeDiet score
both with a low GL
offer protection of
about 20% against
diabetes
The overall
adherence to the
MeDiet was low
(most subjects
succeeded 6-9 points
on a 0-14 point scale)
No differences in
mean age, physical
activity, education
and consumption of
antiplatelet and βblocker agents were
found across
categories of
adherence
Participants with
higher adherence to
MeDiet were more
likely to be women
Subjects with MetS
were less likely to
consume olive oil
and vegetables
BMI and the overall
MeDiet were
strongly associated
with the presence of
MetS
IFG was
independently
predicted by age,
BMI and overall
MeDiet
Adherence to MeDiet
may protect against
MetS and prediabetes
and exert a beneficial
role on glucose
metabolism
The average MeDiet
score was 5 on a 010- point scale
Participants with
higher conformity to
the MeDiet were
more likely to be
female, more
educated, had higher
Inverse associations
observed between
adherence to MeDiet
and the prevalence of
MetS
and
prediabetes due to
the effects of the
entire dietary pattern
Greater consistency
with MedDiet was
associated
with
lower insulin levels
among
nondiabetics, and with
lower blood glucose
before adjustment
for obesity, but not
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
71
ultrasound scanning
-
-
Ryan
2013
et
al.,
Australi
a
Randomized, crossover intervention
study
12 non- diabetic
subjects
(6
female/6 male)
with
biopsy
proven NAFLD
Subjects included if:
- There were evidence
of steatosis on ultrasonography
and
histology
- presence of MetS
- consumption of no
more
than
7/10
standard
alcoholic
drinks per week for
women/men
-.excluded those with
T1/2D
To examine the effect of the
MeDiet on steatosis and
insulin sensitivity
MeDiet
group
compared
to
a
LF/HCD group. All
subjects
undertook
both diets. Insulin
sensitivity
was
determined with a 3-h
hyperinsulinemiceuglycemic
clamp
study, hepatic steatosis
assessed with H- MRS
6
weeks
intervention
- 6 weeks
wash out6weeks
intervention
-
-
-
-
-
Koning et al.,
2011
USA
Prospective cohort
study
41.615
male
health
professionals
Excluded participants
with T2D, CVD( heart
attack, stroke, angina,
or coronary artery
bypass graft), cancer,
or implausible energy
intake (<800 or >4200
kcal/day)
To compare associations of
diet- quality scores, which
were inversely associated
with CVD, with incident
T2D and to test for
differences in absolute- risk
reduction across various
strata
The HEI 2005, the
alternative
HEI
(aHEI),
the
recommended Food
Score, the alternative
MeDiet
(aMedDiet)
Score, and the DASH
score were calculated
from FFQs quintiles
and
continuous
intervals.
Questionnaires were
mailed to participants
every 2-4 years from
1986 to access lifestyle
and health status.
FFQs were completed
≤20 years
-
-
incomes, a smaller
waist circumference
and were nonsmokers
Higher adherence to
the MeDiet was
associated with lower
blood glucose and
insulin levels before
adjustments for
obesity
The MeDiet was not
related to the
incidence of T2D
At baseline, the 12
subjects were obese,
had elevated mean
fasting serum
concentrations of
glucose, insulin,
triglycerides, ALT
and GGT
Insulin sensitivity at
baseline was low
(M=2.7±1.0
mg/kg/min-1)
Mean weight loss
was not different
between the two diets
There was a
significant relative
reduction in hepatic
steatosis after
MeDiet compared
with the LF/HCD
Insulin sensitivity
improved with the
MedDiet whereas
after the LF/HCD
there was no change
Participants in the
highest quintile of
adherence to the MD
(aMED > 6)
exhibited a 25%
(95% CI 0.66–0.86)
decreased risk of
T2DM, compared
with those in the
lowest
quintile
(aMED < 3
Alternative HEI,
aMedDiet, and
DASH scores were
significantly
associated with
reduced risk of T2D
with
a
lower
incidence of diabetes
Even without weight
loss, MeDiet reduces
liver steatosis and
improves
insulin
sensitivity in an
insulin
resistant
population
with
NAFLD
Several diet- quality
scores
were
associated with a
lower risk of T2D
and
reflect
a
common
pattern
characterized
by
high intakes of plantbased
foods,
moderate alcohol,
low intakes of red
and processed meat,
sodium,
sugarsweetened beverages
and trans fat
72
Panayota Kailatzi et al.
-
every 4 years
-
-
Gouveri et al.,
2011
Romaguera
al., 2011
et
Greece
Denmar
k,
France,
German
y, Italy,
the
Netherla
nds,
Spain,
Sweden
and the
Retrospective
Casecohort
prospective study
2074 adults, 900
men and 1.174
women(
age,
46.6±14.9 years)
11.994 incident
T2D
case
subjects and a
stratified
subcohort
of
15.798
participants
-
Were excluded :
- individuals without
stored blood or with
prevalent
diabetes
status at baseline ,
- participants within the
lowest and highest 1%
of
the
cohort
distribution of the ratio
of reported total energy
intake:
energy
To investigate the association
between MeDiet and MetS in
a representative sample of the
Athenian population in the
early 1980s
To study the association
between adherence to the
MedDiet and risk of
developing T2D, across
European counties
A cross- sectional
epidemiologic survey
of CVD and their risk
factors, was conducted
in a representative
sample of the adult
Athenian population in
the early 1980s. MetS
was defined according
to criteria of the
National Cholesterol
Education ProgramAdult Treatment Panel
III. MedDiet was
assessed according to
guidelines
of the
Division
of
Nutrition/epidemiolog
y, Athens University
Medical School
A case- cohort study
including
11.994
incident T2D case
subjects
and
a
stratified subcohort of
15.798
participants
selected from a total
cohort of 340.234
participants with 3.99
million person – years
of follow- up from
-
-
-
-
-
4
million
personyears
-
-
A 1-SD increase was
associated with 913% reduced risk of
T2D
DASH score was
associated with lower
risk independently of
other scores
Risk reduction was
greater
among overweight or
obese
subjects,
compared
with
normal-weight
ones (p < 0.01)
49.3% followed
MeDiet with similar
rates across age
groups
MetS was diagnosed
in 24.0% of those
following Med Diet,
compared with
27.9% of those not
following it
Participants with
CVD or T2D were
less likely to follow
Med Diet
MeDiet was
associated with a
20% reduction in
MetS, after
adjustment for age,
gender, smoking,
light physical
activity, serum levels
of low- density
lipoprotein
cholesterol and γglutamyl transferase,
diabetes mellitus,
CVD, family history
of hypertension,
and/or
hyperlipidemia
Individuals with a
high rMeDiet score
range (11-18 points)
were 12% less likely
to develop diabetes
than individuals with
low rMeDiet scores
(0-6 points)
The alcohol, meat,
and olive oil
Adherence
to
MeDiet
may
attenuate
the
prevalence of MetS
and, consequently,
the
increasing
burden of diabetes
mellitus and CVD,
especially in urban
populations
Adherence
to
MedDiet
was
associated with a
small reduction in
the
risk
of
developing T2D
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
U.K
Itsiopoulos
al., 2011
et
Diez- Espino et
al., 2011
Australi
a
Spain
requirement
Randomized crossover study
Crossstudy
sectional
27 people, aged
between 47 and
77 years, with
confirmed T2D
385 participants,
53.4% women
(mean age 69±6
years)
Exclusion
criteria
were: presence of
disabling stroke, cancer
not in remission, renal
failure, or liver disease
Included participants
with T2D
73
eight European cohorts
participating in EPIC
study. The relative
MedDiet score was
used
to
assess
adherence to MedDiet.
Cox
proportional
hazards
regression,
modified for the casecohort design, was
used to estimate the
association between
rMedDiet and risk of
T2D, adjusting for
confounders
To examine the impact of a
traditional Mediterraneantype cuisine on HbA1c and
vascular risk in T2D
To analyze the association
between adherence of a
MeDiet in patients with T2D
and levels of HbA1 c
Participants
were
randomly assigned to
consume either the
intervention diet ad
libitum or their usual
diet for 12 weeks and
then cross over to the
alternate
diet.
Biochemical data and
anthropometric
characteristics
were
assessed at baseline,
and at the end of both
diet periods. Dietary
adherence
was
monitored
using
plasma carotenoid and
fatty acid analysis,
complemented by diet
diaries
Information on diet
was collected with a
validated 14 point
scale of adherence to
the MeDiet and blod
samples were obtained
to assess HbA1c
-
-
-
24 weeks
-
-
-
-
-
-
Salas- Salvado
et al., 2011(10)
Spain
Randomized
controlled trial
418 non diabetic
subjects aged 5580 years
Participants
without
prior CVD but having
at
least
three
cardiovascular
risk
factors:
smoking,
To test the effects of two
MedDiets supplemented with
either extra virgin olive oil or
mixed nuts, versus a low- fat
control diet on incidence of
Participants
were
randomly assigned to
education on a low- fat
diet (control group) or
to
one
of
two
4.0 years
-
components of the
rMeDiet accounted
for the most of the
observed association
Two- point increment
in rMeDiet was
associated with a 4%
reduction in the risk
of T2D
No association
between rMeDiet and
diabetes was
observed among the
youngest participants
The association
between rMeDiet and
diabetes was
attenuated in obese
participants
Compared with usual
diet, on the ad
libitum MedDiet
HbA1c fell from
7.1% to 6.8%
There was a trend
towards improved
insulin sensitivity
Diet quality
improved
significantly
Although there was a
potential inverse nonsignificant
association between
adherence to MeDiet
and HbA1c levels
after adjusting for
age and sex, it was
not statistically
significant
Multivariate analysis
found similar
findings
Diabetes incidence
was 10.1%, 11.0%
and 17.9% in the
MedDiet with olive
oil group, the
A
traditional
MedDiet improves
glycemic control and
diet quality in men
and women with
well controlled T2D,
without
adverse
effects on weight
Although not enough
evidence was found
to
support
that
MeDiet is associated
with lower levels of
HbA1c in patients
with T2D, the results
suggest an inverse
trend
MedDiets without
calorie
restriction
seem to be effective
in the prevention of
diabetes in subjects
74
Elhayany et al.,
2010
Kastorini et al.,
2010
Panayota Kailatzi et al.
Israel
Greece
Prospective
randomized
intervention study
Review
259 overweight,
diabetic patients
(mean age 55
years)
-
hypertension,
dyslipidemia,
overweight
(BMI≥25kg/m2), and
family
history
of
premature CVD, were
included in the study.
Excluded those with
prevalent diabetes, with
severe chronic illness,
alcohol or drug abuse,
BMI ≥40kg/m2, and
history of allergy or
intolerance to olive oil
or nuts
diabetes
Inclusion criteria: age
30- 65 years, T2D
diagnosed within 1-10
years, BMI 27-34
kg/m2, last HbA1c
measurement 7-10%,
last plasma TG level
1.8- 4.5 mmol/l, last
serum
creatinine<123.2mmol/
l, and no change in
diabetes medication for
at least 3 months before
entering study
Exclusion
criteria:
proliferative diabetic
retinopathy,
current
insulin
treatment,
active oncologic or
psychiatric disease and
uncontrolled
hypothyroidism
or
hyperthyroidism
To examine the effects of a
low carbohydrate MedDiet
(LCM),
a
traditional
MedDiet (TM) and the 2003
American
Diabetic
Association diet (ADA), on
CDV risk factors and
diabetes control
-
MedDiets,
supplemented
with
either free virgin olive
oil
(1lt/week)
or
nuts(30gr/day). Diets
were ad libitum. The
main outcome was
diabetes
incidence
diagnosed by the 2009
American
Diabetes
Association criteria.
Questionnaires about
lifestyle
variables,
medical
condition,
medication
use,
conformity to MedDiet
and leisure- physical
activity
time,
administered annually
Participants
were
randomly assigned to
one of the three diets.
The main outcome
measures
were
glycaemic control and
biomarkers
for
cardiovascular
risk.
Adherence to MedDiet
was evaluated from
Food
Frequency
Questionnaire (FFQ)
administered at 6
months
-
-
1 year
-
-
-
-
-
To investigate whether the
protective role of MedDiet on
T2D is a myth or fact
-
MedDiet with nuts
group and the control
group, respectively
When the two
MedDiet groups were
pooled and compared
with the control
group. Diabetes
incidence was
reduced by 52%
In all study arms,
increased adherence
to the MedDiet was
inversely associated
with diabetes
incidence
at
high
cardiovascular risk
Weight, BMI and
waist circumference
were reduced in all
dietary interventions
with no significant
difference between
the groups
HbA1c, blood lipids
and HOMA
decreased in all
groups, fasting
insulin levels
increased over time
The reduction in
HbA1c was
significantly greater
in the LCM diet than
in ADA diet
HDL cholesterol
increased only on the
LCM diet
The reduction in
serum TG was
greater in the LCM
and TM than in the
ADA diet
Many
epidemiological
studies show the
beneficial effect of
the MedDiet on
T2D and glucose
metabolism in
general 2,4,5,23,12,24
Dietary intervention
was effective in
improving
most
modifiable CDV risk
factors on all dietary
groups. Only the
LCM diet improved
HDL levels and was
superior to both the
ADA and TM in
improving
glycaemic control in
overweight diabetic
patients
Results
from
epidemiological
studies and clinical
trials evaluating the
role of the MedDiet,
regarding
the
development
and
treatment of T2D,
indicate
the
protective role of
this pattern
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
Esposito et al.,
2009
Rumawas et al.,
2009
Italy
USA
Crossstudy
sectional
Prospective
901 outpatients
with T2D
2730 participants
without
T2D
(median
age:
54y) for the
analyses of MetS
traits and 1918
participants free
of MetS to assess
the incidence of
MetS
Inclusion criteria: a
diagnosis of T2D for at
least 6 months but< 10
year, age 35-70 years.
BMI ≥ 24.0kg/m2,
HbA1C ≥6.5% and
treatment with diet or
oral glucose- lowering
drugs
Exclusion criteria: need
for
insulin
use,
concomitant
chronic
diseases,
including
kidney, liver and CVD
diseases, resent acute
illness or change in
diet,
treatment
or
lifestyle within the 3
months before the
initial assessment
To Explore whether a
MedDiet
improves
glycaemic control in diabetes
Excluded participants
with diabetes and
missing or invalid FFQ
data, those who did not
attend the follow-up
and those who were
missing covariates.
Participants
with
prevalent MetS at
baseline were also
excluded
To examine the prospective
association between the
MedDiet and metabolic
syndrome
75
Subjects were asked to
measure home blood
glucose and fasting
glucose level on three
and
two
nonconsecutive
days
respectively, during a
period of 1 month.
Subjects were invited
to follow their usual
treatment and eat their
usual diet during the
month. Blood sample
was obtained. Diet
history was collected
twice (at entry and 1
month later). Nutrient
intakes were assessed
using FFQ. Adherence
to
MedDiet
was
measured with a 0-9
point
scale
questionnaire
Adherence to MedDiet
was measured with
MSDPS.
Dietary
intake was assessed by
using the Harvard
semiquantitative FFQ.
The
association
between MSDPS and
MetS
traits
homeostasis
model
assessmentinsulin
resistance,
fasting
glucose,
waist
circumference,
triglyceride,
HDL,
cholesterol
and
systolic and diastolic
blood pressure was
examined
-
-
-
Mean time:
7 years
-
-
-
Diabetic patients
with the highest
scores (6-9) had
lower BMI, waist
circumferences, a
lower prevalence of
the MetS and lower
HbA1c and post- meal
glucose levels than
diabetic patients with
the lowest scores (03).
Mean HbAic and 2-h
post- meal glucose
concentrations were
significantly lower in
diabetic patients with
high adherence to
MedDiet than those
with low adherence
In T2D, greater
adherence
to
MedDiet
is
associated
with
lower HbAic and
postprandial glucose
levels
Participants in the
highest quintile
category were older,
more likely to be
women, multivitamin
users, and ERT users,
more likely to have a
greater change in
BMI over follow-up,
and less likely to be
current smokers
A higher MSDPS
was associated with
lower homeostasis
model assessmentinsulin resistance,
waist circumference,
fasting plasma
glucose, and
triglycerides and
higher HDL
cholesterol after
adjustment for the
corresponding
baseline values and
for several
confounding factors
associated with T2D
risk
Participants in the
highest quintile
category of the
MSDPS had a lower
incidence of MetS
Consuming a diet
consistent with the
principles of the
MedDiet
was
favorably associated
with avoiding MetS
traits- specifically
with less abdominal
obesity, less insulin
resistance, and less
atherogenic
dyslipidemia. The
study also showed
that a diet consistent
with a MedDiet was
associated with a
lower incidence of
MetS
76
Babio
2009
Panayota Kailatzi et al.
et
al.,
Champagne et
al., 2009
Spain
Review
-
USA
Review
-
To analyze the effect of diet
on MetS and its components
Review
of
the
available literature in
relation to MedDiet
and MetS
To review the usefulness of a
Mediterranean- based diet in
individuals with T2D
This article reviews
data available on the
MedDiet related to its
use in a diabetic
population
-
-
-
-
-
Giugliano et al.,
2008
Italy
Review
-
To
present
evidence
illustrating the relationship
between MedDiets and
metabolic diseases, including
obesity, T2D, and the MetS,
and to briefly discuss
potential mechanisms by
which these diets can help in
disease
prevention
and
treatment
-
-
-
-
-
-
than those in the
lowest quintile
category
Several components
of MedDiet patterns
have been inversely
related with BMI.
They are considered
to be modulators of
insulin resistance,
can exert beneficial
effects on blood
pressure, improve
atherogenic
dyslipidemia or
attenuate the
inflammatory burden
associated with MetS
Mediterranean diet
may be used in
dietary interventions
for the treatment of
overweight and
obesity, conditions
associated with the
development of T2D
MedDiet has been
found to be inversely
related to the MetS,
often a feature of
diabetic individuals
Consuming MedDiet,
there was a positive
response of insulin,
blood glucose, blood
lipids, and other
metabolic factors
predicting CVD risk
and outcomes
Mounting evidence
indicates a favorable
effect of MedDiet on
obesity and T2D
MedDiet is
attenuating the
inflammatory burden
associated with T2D
A lower prevalence
of the MetS is
associated with
dietary patterns rich
in fruits, vegetables,
whole grains, dairy
products, and
unsaturated fats
Both epidemiological
and interventional
MedDiet could serve
as
an
antiinflammatory
dietary
pattern,
which could help to
fight diseases related
to
chronic
inflammation,
including MedS
The review of the
literature points to
using the MedDiet as
a viable option for
people with T2D.
Advisors
should
stress
not
only
adherence to a fairly
MedDiet but also a
lifestyle
that
includes sufficient
physical activity
Mounting evidence
suggests
that
MedDiets
could
serve as an antiinflammatory
dietary
pattern,
which could help
fighting diseases that
are related to chronic
inflammation,
including
visceral
obesity, T2D and the
MetS
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
77
studies have revealed
a protective effect of
the MedDiet against
mild chronic
inflammation and its
metabolic
complications
Sanchez- Tainta
et al., 2008
Brunner et al.,
2008
Spain
UK
Cross- sectional
Prospective
analysis
3204
asymptomatic,
high
cardiovascular
risk individuals
7731 participants
with mean age of
50y
Eligible
participants
were
communitydwelling men, 55-80
years old, and women,
60-80 years old, who
have diabetes or who
meet at least three or
more other CVD risk
factors
Exclusion
criteria
were: previous history
of CVD, any severe
chronic illness, drug or
alcohol addiction, and
history of allergy or
intolerance to olive oil
or nuts
To estimate the association
between adherence to a
MedDiet and the prevalence
of
hypertension,
dyslipidemia, diabetes and
obesity, or their clustering in
a
large
sample
of
asymptomatic high- risk
patients
Excluded participants
who were members of
outlying
dietary
clusters, and energy
misreporters
To analyze the prospective
relation of dietary patterns
with incident chronic disease
and mortality
Trained
personnel
made weight, height,
blood
pressure,
diabetes
testing,
hypertension,
and
hypercholesterolemia
measurements. A 14item
questionnaire
specifically designed
to assess adherence to
the
traditional
MedDiet and a 137item
FFQ
were
administered
-
-
-
-
Dietary patterns were
identified in order to
study their relations to
incident
major
coronary events and
diabetes as well as
mortality. Follow –up
carried out by means of
screening
contacts
every 5y. Usual dietary
intake was assessed by
using a 127- item FFQ.
Coronary death or
nonfatal myocardial
infarction and incident
diabetes were verified
by record tracing and
oralglucosetolerance tests
15 years
-
-
Adherence to
MedDiet was
inversely associated
with individual risk
factors and, above
all, with the
clustering of them
The multivariate
adjusted odds ratio to
present
simultaneously the 4
risk factors for those
above the median
value of the MedDiet
score was 0.67
The multivariate odd
ratios for successive
categories of
adherence to
MedDiet were 1,
1.03, 0.85, 0.7 and
0.54
4 dietary patterns
were identified at
baseline:
unhealthy( white
bread, processed
meat, fries, and fullcream milk),
sweet( white bread,
biscuits, cakes,
processed meat, and
high fat dairy
products),
Mediterraneanlike( fruit,
vegetables, rice,
pasta, and wine), and
healthy ( fruit,
vegetables, wholemeal bread, low-fat
dairy, and little
alcohol
Compared with the
unhealthy pattern, the
healthy pattern
reduced the risk of
Following
the
MedDiet
was
inversely associated
with the clustering of
hypertension,
diabetes,
obesity,
and
hypercholesterolemi
a among high- risk
patients
The healthy eating
pattern reduced risks
of diabetes and
major
coronary
events. Such dietary
patterns
offer
considerable health
benefits
to
individuals
78
Panayota Kailatzi et al.
-
MartinezGonzalez et al.,
2008
Tzima et
2007
al.,
Spain
Greece
Prospective cohort
study
Crossstudy
sectional
13.380 Spanish
university
graduates
without diabetes
at baseline
1762 participants
with excess body
weight, meaning
overweight( BM
I: 25- 29.9kg/m2)
and obese (BMI>
30kg/m2), 20-89
years old
Excluded participants
who had diabetes at
baseline and those who
reported a baseline
history of CVD
Included
people
without any clinical
history of CVD, or any
other atherosclerotic
disease, as well as
chronic viral infections.
Participants did not
have cold or flu, acute
respiratory infection,
dental problems or any
type of surgery during
past weeks. All people
living in institutions
were excluded from the
study
To assess the relation
between adherence to a
MedDiet and the incidence of
diabetes among initially
healthy participants
To investigate if overweight
and obese adults ‘’close’’ to
MedDiet
present
better
insulin, lipids profile and
better
pressure
levels,
compared to individuals
close to a more Westernized
diet
Dietary habits assessed
at baseline with a 137item FFQ with a 9
point
index.
Adherence to MedDiet
was
appraised
according to the score
created
by
Trichopoulou et al.
Every 2 years, followup questionnaires on
diet, lifestyle, risk
factors, and medical
conditions, were send
to participants. New
cases of diabetes
confirmed
through
medical reports and an
additional
detailed
questionnaire posted to
those who self reported
a new diagnosis of
diabetes by a doctor
during follow- up
Adherence to MedDiet
was assessed through a
FFQ. Blood pressure,
fasting glucose, insulin
and blood lipids were
measured.
Insulin
sensitivity was also
assessed
by
the
HOMA approach
A median of
4.4years
-
-
-
-
-
-
coronary death or
nonfatal myocardial
infarction and
diabetes
Dietary pattern was
not associated with
all- cause mortality
Participants with
high adherence to the
MD (MDS > 6)
exhibited a 83%
(95% CI 0.04–0.72)
reduced
risk
of
T2DM,
compared
with those with low
adherence (MDS < 3)
The incidence rate
ratios adjusted for
sex and age were
0.41 for those with
moderate adherence
( score 3-6) and 0.17
for those with the
highest adherence
(score 7-9) compared
with those with low
adherence (score < 3)
A 2-unit increase in
the MDS score was
associated with a
35% (95% CI 0.44–
0.95) reduced risk of
T2DM
Individuals with
excess bodyweight in
the highest tertile of
diet score, were more
insulin sensitive than
those in the lowest
tertile, had 13%
lower levels of total
cholesterol and
3mmHg decrease of
systolic blood
pressure levels when
adjusted for age, sex
and BMI
Multivariate analysis
after taking into
account several
confounders
demonstrated that
insulin sensitivity,
total cholesterol and
systolic blood
pressure were
Adherence to a
MedDiet
is
associated with a
reduced risk of
diabetes
Overweight
and
obese
people,
attached
to
the
MedDiet, had a
limited profit against
cardiovascular risk
factors.
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
Esposito et al.,
2007
Italy
Schroder et al.,
2007
Spain
Review
-
Review
-
To review the association
between MedDiet and MetS
To
discuss
potential
mechanisms by which the
MedDiet prevents
besity and diabetes
79
-
-
-
-
-
-
-
-
-
-
-
-
independently but
only modestly
correlated with
MedDiet in people
with excess
bodyweight
Dietary patterns close
to MedDiet, rich in
fruit and vegetables,
and high in
monounsaturated fats
are negatively
associated with
features of the
MetS( abdominal
obesity, insulin
resistance,
hypertension,
dyslipidemia)
High fiber diets, such
as MedDiet, increase
satiety and reduce
hunger
Olive oil
consumption was not
associated with
increased weight gain
but with lower
insulin resistance
The average density
of the MedDiet is
remarkably lower
than that reported for
the US
Diets preventing
weight gain, such as
the MedDiet, exert a
protective effect on
the development of
T2D
MedDiet protects
individuals from
oxidative stress, that
is responsible for
pathogens of T2D
Polyphenol- rich
foods seems to exert
a protective effect on
the development of
T2D
High adherence to
the MedDiet is
associated with a
high consumption of
magnesium and
reduced risk of T2D
The
favorable
benefit/ hazard ratio
makes
MedDiets
particularly
promising to reduce
the cardiovascular
burden associated
with the MetS
Several mechanistic
links offer potential
explanations of the
MedDiet’s
protective effect on
obesity and T2D
80
Panayota Kailatzi et al.
-
-
Panagiotakos et
al., 2007
Greece
Cross- sectional
3042 participants
Subjects with history of
CVD or any other
atherosclerotic disease,
with chronic viral
infections, those who
had a cold or flu, acute
respiratory infection,
dental problems or any
type of surgery during
the past weeks were
excluded. Subjects with
type 1 diabetes were
also excluded
To
investigate
the
associations
between
adherence to MedDiet and
fasting indices of glucose
homeostasis
T2D and IFG were
defined according to
the established ADA
criteria.
Insulin
resistance
was
evaluated by HOMAIR. Dietary habits were
assessed through a
validated FFG and a
diet score (range 0-55)
was developed (higher
values means greater
adherence
to
the
MedDiet
-
-
-
-
-
-
Panagiotakos et
al., 2007
Cyprus
Cross- sectional
150
subjects,
aged 65 to 100
years
People with clinical
history of CVD and
those
living
in
institutionswere
excluded from the
To investigate the association
of MedDiet on clinical status
elderly people
A diet score that assess
the
inherent
characteristics of the
MedDiet
was
developed (range 0-
-
-
Moderate alcohol
drinking, such as in
the MedDiet, was
associated with a
30% risk reduction of
T2D
Dietary fiber, in
particular cereal
fiber, exert a
protective effect on
insulin sensitivity
and the risk of T2D
The overall
prevalence of T2D
was 7.9% in men and
6.0% in women
Mean diet score was
26.3± 6.8 in
normoglycemic,
25.7±6.4 in IFG, and
22.2±5.8 in diabetic
subjects
In normoglycemic
subjects in the upper
tertile of the diet
score, was observed
7% lower glucose,
5% lower insulin and
15% lower HOMAIR compared to
subjects in the lower
tertile
In diabetic/IFG
subjectsinf the upper
tertile of the diet
score, was observed
15% lower glucose,
15% lower insulin
and 27% lower
HOMA-IR levels
compared to those in
the lower tertile
After multiple
regression analysis,
was observed, only in
normoglycemic
subjects an inverse
relationship between
diet score and fasting
plasma glucose,
insulin and HOMAIR levels
Mean diet score had
no differences
between men and
women
Adherence
to
MedDiet was related
to better fasting
indices of glucose
homoeostasis
in
normoglycemic
people, but not in
diabetic or prediabetic
Adherence to the
MedDiet
is
associated
with
reduced odds of
having
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
study
81
-
55). Lifestyle habits
were evaluated and
clinical characteristics
were measured.
Adoption
of
the
MedDiet
was
evaluated against the
presence
of
hypertension, diabetes,
hypercholesterolemia
and obesity
-
-
-
-
-
Lindeberg et al.,
2007
Sweden
Randomized
controlled
intervention
(type 1)
trial
29 male IHD
patients
with
waist
circumference
>94cm
and
increased blood
glucose
or
known diabetes
Included patients with
an
ongoing
acute
coronary syndrome, a
history of myocardial
infarction diagnosed by
creatine kinase MB
isoenzyme or troponin
elevation, percutaneous
coronary intervention
or coronary artery
bypass surgery or
angiographically
diagnosed
coronary
stenosis
≥
30%.
To examine the effect of the
Paleolithic
diet
model,
compared
to
the
Mediterannean- like diet on
glucose
tolerance
and
postchallenge
insulin
response
in
glucoseintolerant IHD patients
Participants
were
randomized to receive
a Paleolithic diet,
based on lean meat,
fish fruits, vegetables,
root vegetables, eggs
and
nuts,
or
a
Mediterraneanlike
diet based on whole
grains, low- fat dairy
products, vegetables,
fruits, fish, oils and
margarines. Outcome
variables were changes
3 months
-
-
-
The level of
adherence to
MedDiet was 64%
More than 9 out of
10 of the participants
reported that they
followed the reported
dietary habits for at
least 30- 40 years of
their life
MedDiet score was
inversely correlated
with BMI, total
cholesterol,
triglycerides,
glucose, and systolic
blood pressure levels
Taking into account
age, sex, smoking
habits and physical
activity status, was
observed that 10-unit
increase in the diet
score was associated
with 17% lower odds
of having one
additional risk factor
Stratified the analysis
by gender, the
reduction in the odds
was 21% in women
and 14% in men
A 10- unit increase in
the diet score was
associated with a 6%
lower odds of having
hypertension, 9%
lower odds of having
hypercholesterolemia
, 6% lower odds of
having diabetes and
12% lower odds of
being obese
There was a 26%
decrease of AUC
glucose 1-120 in the
Paleolithic group
and a 7% decrease in
the MedDiet group
The larger
improvement in the
Paleolithic group was
independent of
change in waist
circumference
In the study
population as a
hypercholesterolemi
a,
hypertension,
diabetes and obesity
among
elderly
people
A Paleolithic diet
may
improve
glucose tolerance,
independently
of
decreased
waist
circumference.
Subjects
who
followed
the
MedDiet did not
significantly
improve
their
glucose
tolerance
despite decreases in
weight and waist
82
Tortosa et al.,
2007
Panayota Kailatzi et al.
Spain
Prospective cohort
study
2.563
participants
initially free of
MetS or risk
factors
Exclusion criteria were
BMI < 20kg/m2 , serum
creatinine>130μmol/l,
poor general condition,
dementia,
unwillingness/inability
to prepare food at
home, participation in
another medical trial,
chronic inflammatory
bowel disease, type 1
diabetes and treatment
with
hypoglycaemic
agents, warfarin or oral
steroids. Other drugs
were not restricted and
treatment with statins
and beta blockers was
usually initiated and/or
changed during the
trial.
Participants
were
excluded if at baseline
they had implausible
values for total energy
intake,
had
BMI>30kg/m2
or
reported risk factors
(diabetes,
hypertension,
hypercholesterolemia,
or
hypertriglyceridemia),
or met the criteria for
MetS
in
weight,
waist
circumference
and
plasma glucose AUC
and plasma insulin
AUC in OGTTs
To assess the relationship
between adherence to the
MedDiet and the subsequent
development of MetS
Baseline assessment of
participants consists of
a self- administered
questionnaire,
gathering information
on lifestyle factors and
including a 136- item
FFQ.
Biennially
mailed
follow-up
questionnaires were
used
to
collect
information about diet,
lifestyle and medical
conditions. MetS was
defined according to
the
International
Diabetes Federation
criteria
A median of
74 months
-
-
-
-
Mozzaffarian et
al., 2007
Italy
Prospective
8291
patients
with
a
myocardial
infarction within
the previous 3
months,
who
were free of
diabetes
Excluded individuals
with prevalent diabetes
at enrolment, those
with
missing
information about diet
or weight at baseline, or
about
glucose
at
baseline or during
follow- up
To estimate the incidence of
new- onset diabetes and IFG
in patients with recent
myocardial infarction and
investigate whether dietary
habits might alter this risk
Incidence of newonset diabetes and IFG
were
assessed
at
follow- up at 0.5, 1.0,
1.5, 2.5, and 3.5 years.
Data for BMI, other
risk factors, dietary
habits and medications
were updated during
follow- up. A MedDiet
score was assigned
Mean time:
3.2 years
-
whole, there was no
relationship between
change in AUC
Glucose0-120 and
changes in weght or
waist circumference
circumference.
Healthy diets based
on
wholegrain
cereals and low-fat
dairy products are
only the second best
choice
in
the
prevention
and
treatment of T2D
Adherence to the
MedDiet was higher
among women, older
subjects, ex-smokers,
and more physically
active participants
Participants with
higher baseline
adherence to the
MedDiet exhibited
lower levels of all
risk factors except
plasma glucose
HDL levels were
higher among
participants who
better adhered to the
MedDiet
Subjects with the
highest adherence to
the MedDiet had
lower cumulative
incidence of MetS
than those with the
lowest adherence
Participants in the
highest quintile of
adherence to the MD
(MD score > 10)
exhibited a 35%
lower risk of T2DM
(95% CI 0.49–0.85),
compared with
those in the lowest
quintile (MD score <
6)
MedDiet inversely
associated with the
incidence of MetS
Myocardial
infarction could be a
prediabetes
risk
equivalent. Smoking
cessation, prevention
of weight gain and
consumption
of
typical
Mediterranean foods
might lower this risk
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
83
-
according
to
consumption
of
cooked
and
raw
vegetables, fruit, fish,
and
olive
oil.
Associations
of
demographic, clinical,
and lifestyle riskfactors with incidence
of diabetes and IFG
were assessed with
multivariable
Cox
proportional hazards
-
-
-
-
Michalsen
al., 2006
et
German
y
Randomized,
controlled trial
101
patients(59.4±8.
6
years,
23%female) with
established and
treated CAD
Excluded individuals
with an ACS or CABG
within the previous 3
months,
diabetes
mellitus
type1,
manifest
cardiac
arrhythmias,
heart
failure, life- threatening
comorbidity and BMI>
33kg/m2
To investigate the effect of
MedDiet on markers of
inflammation and metabolic
risk factors in patients with
treated CAD
Participants
were
assigned to a MedDiet
group with 1- year
program of 100h of
education, or to a
written advise - only
group. Before and after
intervention, serum hsCRP , fibrinogen,
fasting
insulin,
homocysteine, serum
lipids and plasma fatty
acids were measured
1 year
-
-
The average age was
59 years, and 13% of
participants were
women
Patients were on
average overweight
(mean BMI:
26.3kg/m2 )and 13%
were obese
Greater intake of
MedDiet was
associated with older
age, being female,
slightly greater BMI,
hypertension,
previous acute
myocardial infarction
and former rather
current smoking
Independent risk
factors for newonset diabetes or IFG
included older age,
hypertension, use of
beta- blockers, lipidlowering
medications(protectiv
e) and diuretic use
Independent lifestyle
risk factors included
higher BMI, greater
BMI gain during
follow-up, current
smoking, a lower
MedDiet score and
wine consumption of
more than 1l/day
The MedDiet group
individuals, increased
the intakes of fish,
fruits/vegetables and
moderately of
canola/olive oil and
increased plasma
concentrations of
long- chain n-3
polyunsaturated fatty
acids
Median hs-CRP and
mean fibrinogen,
homocysteine,
fasting insulin,
triglycerides and
serum cholesterols
remained unchanged
in both groups
Adoption
of
a
MedDiet by patients
with
medically
treated CAD has no
effect on markers of
inflammation
and
metabolic
risk
factors
84
Estruch et al.,
2006
Panayota Kailatzi et al.
Spain
Randomized trial
772
asymptomatic
persons 55 to 80
years old at high
cardiovascular
risk
Eligible
participants
were
communitydwelling men, 55 to 80
years old and women,
60 to 80 years old, who
fulfilled at least 1 of 2
criteria: T2D or 3 or
more
CHD
risk
factors(current
smoking, hypertension,
LDL cholesterol level
≥4.14mmol/L,
HDL
cholesterol
level
≤1.04mmol/L.
Exclusion criteria were
history of CVD, any
severe chronic illness,
drug alcohol addiction,
history of allergy or
intolerance to olive oil
or nuts, or low
predicted likelihood of
changing dietary habits
according to the stagesof- change model
To compare the short term
effects of 2 MedDiets versus
those of a low- fat diet on
intermediate markers of
cardiovascular risk
Participants
were
assigned to one of two
MedDiets (with virgin
oil or with mixed nuts)
or to a low- fat diet.
Those allocated to
MedDiets
received
nutritional education.
A
14item
questionnaire assessed
the
degree
of
adherence
to
the
MedDiet. FFQ and a
47-item questionnaire
about
education,
lifestyle, history of
illness, and medication
use,
were
used.
Anthropometric and
blood
pressure
measurements
were
performed,
and
samples of fasting
blood and spot urine
were obtained
3 months
-
-
-
-
VincentBaudry et al.,
2005
France
Intervention study
212 subjects with
moderate
risk
factors for CVD
Participants met at last
one of the following
criteria: fasting plasma
cholesterol
concentration of 6.57.7mmol/L,
triacylglycerol
concentration of 2.14.6
mmol/L,
glycemia(glucose
concentration of 6.16.9 mmol/L), systolic
and diastolic blood
pressure between 140-
To investigate the effects of a
MedDiet or a low-fat diet on
cardiovascular risk factors
After the 3- month
dietary intervention,
changes in many risk
factors were evaluated.
Dietary questionnaires
and plasma nutritional
markers were used to
test compiance
3 months
-
-
-
Compared with the
low- fat diet, the 2
MedDiets decreased
systolic(-5.9mm/Hg
and -7.1mm/Hg
respectively for
MedDiet with olive
oil and MmedDiet
with nuts) and
diastolic blood
pressure, blood
glucose levels(0.39mmol/L and –
0.30mmol/L
respectively for
MedDiet with olive
oil and MedDiet with
nuts), and
cholesterol- HDL
cholesterol ratio ( 0.38 and -0.26,
respectively for
MedDiet with olive
oil and MedDiet with
nuts ) and increased
HDL cholesterol
levels
Fasting insulin levels
and HOMA scores
were also lower in
participants without
diabetes in the 2
MedDiet groups
Total cholesterol and
triglyceride levels
decreased only in the
MedDiet with nuts
The MedDiet with
olive oil reduced Creactive protein
levels by 0.54mg/L
compared with the
low- fat diet
The mean age of the
subjects was
50.8±10.8 and
51.6±10.3 in the
MedDiet group and
the low-fat group
respectively
35% of the subjects
were overweight and
38% were obese
Changes in dietary
habits were observed
in both groups
Participants
who
improved
their
baseline MedDiet,
showed lower blood
pressure, improved
lipid
profiles,
decreased
insulin
resistance
and
reduced
concentrations
of
inflammatory
molecules compared
with those allocated
to a low- fat diet.
MedDiets
have
beneficial effects on
cardiovascular risk
factors
Both
diets
significantly reduced
CVD risk factors
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
85
-
180 and 90-105mmHg,
respectively, BMI>27,
smoking, sedentary or
family history of CVD.
Subjects treated with
hypolipemic
or
hypoglycemic
drugs
were excluded
-
Panagiotakos et
al., 2005
Greece
Cross-sectional
3042
subjects
with no evidence
of CVD or any
other
chronic
disease
Participants with type 1
diabetes, history of
CVD or any other
atherosclerotic disease
were excluded.
To evaluate the prevalence of
T2D in a Greek adult
population, in relation to
physical activity and dietary
habits
Diabetes was defined
according
to
the
established
ADA
criteria. Dietary habits
were assessed through
a validated FFQ and a
diet score measured
the adherence to the
MedDiet.
Weekly
energy
expenditure
was
assessed
by
considering frequency,
duration and intensity
of
sports-related
physical activity
-
-
-
-
-
-
-
BMI, total and
triacylglycerol- rich
lipoprotein (TRL)
cholesterol,
triacylglycerols, TRL
triacylglycerols,
apolipoproteins A-I
andB, insulinemia,
glycemia and the
HOMA score were
significantly lower
after 3 months
There was a 9%
reduction in CVD
risk with the low-fat
diet and a 15%
reduction with the
MedDiet
The projection
prevalence of
diabetes was 7.6% in
men and 5.9% in
women
Diabetic people were
less likely to smoke,
less physically active
and less educated
than the participants
without diabetes
Diabetic people were
less devoted to the
MedDiet compared
with participants
without diabetes
The prevalence of
diabetes in a person
with no physical
activity was 4.6%
and in low physical
active people was
4.2%. The relative
risk reduction was
9.5%
Increasing age,
smoking habits,
family history of
diabetes, elevated
systolic blood
pressure and
triglycerides levels
were significantly
associated with the
presence of diabetes
24% of men and
30% of women were
unaware of their
condition
Light
physical
activity and greater
adherence to the
MedDiet
was
associated
with
significantly lower
odds of having
diabetes
86
Panayota Kailatzi et al.
-
-
Toobert et al.,
2003
USA
Randomized
controlled trial
279
postmenopausal
women
with
T2D
Inclusion criteria were
female sex, diagnosis
of T2D for at least 6
months,
postmenopausal, living
independently, having
a telephone, able to
read
English,
not
developmentally
disabled and living
within 30 miles of the
intervention
site.
Exclusion criteria were
being >75 years of age
or planning to move
from the area within the
study’s time span
To test the effectiveness of
the Mediterranean Lifestyle
Program(MLP)(Mediterrane
an low-saturated fat diet,
stress management training,
exercise, group support and
smoking
cessation),
in
reducing cardiovascular risk
factors in postmenopausal
women with T2D
Participants
were
randomized to either
usual care control or
treatment
(MLP)
conditions.
MLP
participants took part
in an initial 3-day
retreat followed by 6
months of weekly
meetings to learn and
practice
program
components.
Biological end points
were
changes
in
HbAc1c , lipid profiles,
BMI, blood pressure,
plasma fatty acids, and
flexibility. Impact on
quality of life was
assessed
6 months
-
-
-
A 10-unit increase in
the diet score was
associated with 21%
lower odds of
diabetes
Individuals taking
light physical activity
were at 35% lower
odds ratio of diabetes
compared to
sedentary individuals
HbA1c decreased
from 7.43 to
7.07mg/dl for the
MLP women,
HbA1c remained at
7.4mg/dl for the
control subjects, this
would translate into a
14% reduction in risk
of diabetes
complications
A drop of 0.37 in
BMI observed in the
MLP women and an
increase of 0.20 in
BMI for the control
group
Quality of life
improved
significantly for the
MLP women
Postmenopausal
women with T2D
can
make
comprehensive
lifestyle changes that
may
lead
to
clinically significant
improvements
in
glycemic
control,
some coronary heart
disease risk factors
and quality of life
Effects of the Mediterranean Diet on Type 2 Diabetes' Incidence and Treatment
5
87
Discussion
The MeDiet has been widely reported to be a model of healthy eating for its contribution
to a favourable health status, better biochemical profile and a better quality of life. In the
present review, the role of the MeDiet in T2D prevention and treatment, as well as its
potential protective mechanisms against the MetS and CVD, were briefly presented [28,
29]. According to epidemiological data, a greater adherence to the MeDiet, as assessed by
various MeDiet indices, is inversely associated with T2DM risk in the general population,
in individuals at high cardiovascular risk and in patients with established CVD.
Interventional studies also demonstrate the beneficial role of the MeDiet in T2D
management, with patients allocated to a MeDiet exhibiting greater improvements in
glycemic control and CVD risk factors, compared with those following a control diet [12,
22, 25, 26].
Although this review provides useful information, all studied outcomes must be interpreted
with caution because of some weaknesses. The wide variety of available MeDiet scores
makes it difficult to compare the results of studies, in which different scores are used. This
observation, along with the fact that diet varies significantly across populations, suggest
that an analysis of this type cannot provide universally applicable results [67]. In addition,
MeDiet indices may not precisely describe the overall MeDiet, since most available scores
focus on selected aspects of the diet and involve some level of arbitrary decision in the type
and number of components to be included as well as their scoring system [68]. Secondly,
the availability of few controlled trials designed to evaluate the metabolic and
cardiovascular outcomes of the MeDiet specifically in MeDiet, as well as the fact that most
clinical studies focused on surrogate markers for early CVD risk assessment, signify major
limitations of the present review. Moreover, some major randomized controlled trials,
which showed that intensive lifestyle interventions can reduce the incidence of T2D in
individuals at high risk for T2D in the general population, did not decrease the risk of CVD
and CVD-associated mortality [69,70].
Although some relevant differences among the studies are present and further long-term
intervention trials are crucial in evidencing the long-term efficacy in the T2D prevention
and treatment, strategies aiming to promote adherence to MeDiet dietary pattern are of
considerable public health interest [71,72].
6 Conclusion
In conclusion, this review seems to be clinically relevant in terms of public health,
particularly for reducing the risk of premature death in the general population, and is strictly
concordant with current guidelines and recommendations from all the major scientific
associations that strongly encourage a Mediterranean-like dietary pattern for primary and
secondary prevention of major chronic diseases [26]. Indisputably, the development and
implementation of national policies for the prevention of T2D and its complications with
optimum efficiency and minimum cost is the only way to reduce the personal and socioeconomic burden of the disease and its complications.
88
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